Author Affiliations: Harvard Children's Initiative, Harvard University (Dr Silverman), Department of Social and Behavioral Sciences, Boston University School of Public Health (Dr Raj), Bureau of Health Statistics, Research, and Evaluation (Ms Mucci), and Bureau of Family and Community Health (Dr Hathaway), Massachusetts Department of Public Health, Boston. Dr Silverman is now with the Division of Public Health Practice and Department of Health and Social Behavior, Harvard School of Public Health, Boston.

ABSTRACT

Context Intimate partner violence against women is a major public health concern.
Research among adults has shown that younger age is a consistent risk factor
for experiencing and perpetrating intimate partner violence. However, no representative
epidemiologic studies of lifetime prevalence of dating violence among adolescents
have been conducted.

Objective To assess lifetime prevalence of physical and sexual violence from dating
partners among adolescent girls and associations of these forms of violence
with specific health risks.

Conclusion Dating violence is extremely prevalent among this population, and adolescent
girls who report a history of experiencing dating violence are more likely
to exhibit other serious health risk behaviors.

Intimate partner violence (IPV) against women is a major public health
concern. Estimates from a recent large-scale, nationally representative survey1 indicate that more than 1.5 million women are physically
and/or sexually abused by an intimate partner each year in the United States,
and 25% will experience IPV at some point during their lifetimes. Research
among adults has shown that younger age is a consistent risk factor for experiencing
and perpetrating IPV.2- 4
Rates of IPV among nonrepresentative samples indicate that approximately 25%
of adolescents have experienced physical and/or sexual dating violence,5,6 an estimate consistent with the estimated
lifetime prevalence of IPV among adult women.1
However, no representative epidemiologic studies of lifetime prevalence of
physical and sexual dating violence experienced by adolescents have been conducted
to provide a reliable estimate of the scope of the problem, indicate which
groups of adolescents may be at greatest risk, or assess whether other health
risks faced by adolescents are associated with a history of IPV.

Most IPV is directed at women. The rate of violence against females
by intimate partners is 3 to 6 times that of IPV against males.1,2
Injuries that result from such violence are significantly more common among
females for both adolescent7 and adult populations,1 and approximately 10% of intentional injuries to adolescent
girls are reported to be the result of violence from male dating partners.8 Furthermore, according to Uniform Crime Reports from
the US Department of Justice,9 females are
approximately 10 times more likely to be killed by an intimate partner than
are males. For these reasons, research and prevention efforts are appropriately
focused on violence against female partners.1,10

Recent events involving fatal violence perpetrated by adolescents have
focused additional attention on all forms of youth violence,11
and there are increasing calls for epidemiologic study of IPV against adolescent
girls,12 in particular. A broad range of physical
and mental health concerns have been shown to be associated with IPV among
women,13 and similar morbidity risks are considered
likely for adolescents.14 Despite these concerns,
little is known of the prevalence or associated health risks of physical and
sexual dating violence against adolescent girls.

Public health surveillance surveys represent an important opportunity
to collect representative data on the extent of behaviors or experiences that
threaten the health of young people and to examine associations among these
risk factors. Because lack of such information is a major barrier to improvement
of identification, treatment, and efforts to prevent adolescent dating violence,
inclusion of queries related to dating violence in such surveys has been recommended.10

Previous representative studies have used adolescent health surveys
to collect data on severe and/or restricted forms of physical violence involving
dating partners (eg, being "beaten up" by a dating partner in the past 30
days or 12 months, boyfriend/girlfriend involved in most recent physical fight
among those involved in physical fighting in the past 30 days).15- 17
The present study advances such work by providing a more comprehensive assessment
of dating violence (including sexual violence) and extending the reporting
period for these experiences. The present analyses (1) provide estimates of
the lifetime prevalence of physical and sexual dating violence, (2) identify
demographic characteristics of those most at risk, and (3) assess dating violence
history as a predictor of behaviors related to major areas of adolescent health
risk (substance use, unhealthy weight control, sexual risk behavior, pregnancy,
and suicidality).

METHODS

The Youth Risk Behavior Survey (YRBS) is conducted in all states every
2 years to track the incidence and prevalence of leading causes of morbidity
and mortality among US high school students. The YRBS is a self-report, written
instrument; in Massachusetts, a Spanish translation of the survey is available.
Each state is charged with administering the core YRBS survey as designed
by the Centers for Disease Control and Prevention. States also have the option
of including additional questions to assess other adolescent health concerns.
In 1997, Massachusetts became the first state to include a question assessing
lifetime prevalence of physical and sexual violence from dating partners on
the YRBS.

The Massachusetts YRBS was administered in both 1997 and 1999 to 9th
through 12th-grade students in randomly selected classrooms within selected
public high schools throughout the state. The probability of an individual
school being selected was proportional to its enrollment. All students, including
those assigned to special education and limited English proficiency classrooms,
were eligible. In 1997, 66 schools were selected and 58 elected to participate,
resulting in a school participation rate of 88%. Of the 5026 students selected
to participate, 3982 completed the survey, resulting in a student participation
rate of 79%. Thus, the overall participation rate (school participation rate
× student participation rate) for the 1997 Massachusetts YRBS was 70%.
Using an identical method, 67 Massachusetts public high schools were chosen
to participate in the 1999 YRBS. Sixty-four schools elected to participate,
resulting in a school participation rate of 96%. A total of 4415 of the 5589
students in selected classrooms completed the survey, resulting in a 79% student
participation rate and an overall 1999 Massachusetts YRBS participation rate
of 75%. Student participation rates for both surveys were similar to attendance
levels on the days of survey administrations. For both years of the survey,
less than 0.5% of students in attendance refused to participate, indicating
a student response rate of more than 99.5%. Scores from individual students
were weighted based on demographics of all students attending Massachusetts
public high schools to provide rates that accurately reflect this population.
These procedures are described in detail elsewhere.18
All results presented are based on analyses of weighted data.

Sample Demographics

The 1997 survey included 1977 female participants; the 1999 survey included
2186. Female participants in both surveys were fairly evenly distributed across
age groups and grades. Most female students were white (73.0% in 1997 and
72.7% in 1999), with smaller percentages of Hispanic (9.4% in 1997 and 11.0%
in 1999), black (6.3% in 1997 and 6.7% in 1999), Asian (5.7% in 1997 and 6.1%
in 1999), and other racial/ethnic group (5.7% in 1997 and 3.5% in 1999) participants.
Assessment of race/ethnicity differed for the 1997 and 1999 YRBSs. The 1999
YRBS included additional race/ethnicity categories of "native Hawaiian/other
Pacific Islander," "multiple Hispanic," and "multiple non-Hispanic." The category
"multiple Hispanic" is collapsed into "Hispanic," "native Hawaiian/other Pacific
Islander" is collapsed into "Asian or Pacific Islander," and "multiple non-Hispanic"is
collapsed into "other" in the present analyses.

Measures

Each variable was assessed via a single item. Because of the nature
of the present analyses, all variables were dichotomized with the exceptions
of age and race/ethnicity, which were categorical as described herein. Physical
and sexual forms of dating violence against adolescent girls were assessed
in the present study. Participants were asked if they had "ever been hurt
physically or sexually by a date or someone they were going out with. This
would include being shoved, slapped, hit, or forced into any sexual activity."
Possible responses included "No, I was not hurt by a date," "Yes, I was hurt
physically," "Yes, I was hurt sexually," and "Yes, I was hurt physically and
sexually." Response categories were not combined to avoid overcounting of
cases within analyses examining both forms of dating violence. Construct validity
of this assessment is indicated by the high percentage of those reporting
sexual dating violence who also indicated ever experiencing forced sexual
contact (78.1% in 1997 and 79.5% in 1999) and the high percentage of those
reporting that their last physical fight was with a dating partner who also
reported physical or sexual dating violence (70.1% in 1997; item not included
in 1999 YRBS) on separate YRBS items. Reliability (ie, replicability) of this
dating violence assessment will be examined through separate analyses of 1997
and 1999 YRBS data sets and tandem presentation of respective results. Substance
use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality
were also measured. Reliability of these measures has been demonstrated elsewhere.19

Data Analyses

Preliminary analyses included χ2 tests of association
between dating violence variables and age and race/ethnicity. Associations
between health risk variables and these demographics also were examined through χ2 analyses. These tests were conducted to provide indications
of whether particular age adolescents or racial/ethnic groups were at relatively
greater risk for sexual and/or physical violence from dating partners and/or
the health risks assessed. Logistic regression equations were constructed
to provide odds ratios (ORs) and 95% confidence intervals (CIs) for the crude
associations of dating violence (sexual, physical, or sexual and physical)
and major areas of adolescent health risk (substance use, unhealthy weight
control, sexual risk behavior, pregnancy, and suicidality). To better understand
these relationships, potential confounders (health risks and demographics
found to be associated with both dating violence variables and health risk
outcomes) were entered into multiple logistic regression equations assessing
all forms of dating violence as predictors of health risk behaviors. In accordance
with procedures recommended by Rothman and Greenland,20
variables that either altered point estimates by more than 10% or were significant
predictors at α = .20 were included in the final models. Analyses assessing
associations between dating violence and sexual risk behaviors or pregnancy
included only participants who reported ever having had sexual intercourse.
Cases involving missing data relevant to analyses were eliminated from those
analyses. SUDAAN software was used to conduct all analyses to account for
the complex sampling design and weighting of the data.21

RESULTS

Descriptive Statistics on Dating Violence and Associations Between
Dating Violence and Demographics

Approximately 1 in 5 (20.2% in 1997 and 18.0% in 1999) female public
high school students in Massachusetts reported ever experiencing physical
and/or sexual violence (ie, reported sexual violence only, physical violence
only, or physical and sexual violence) from dating partners (Table 1). An estimated 1 in 10 (10.1% in 1997 and 8.9% in 1999)
adolescent girls reported being physically abused by a date and not experiencing
sexual dating violence. Approximately 1 in 25 (3.7% in 1997 and 3.8% in 1999)
participants reported ever being sexually assaulted by a date and not experiencing
physical dating violence. A larger number (6.4% in 1997 and 5.3% in 1999)
reported being both sexually and physically assaulted by dating partners.

Table Graphic Jump LocationTable 1. Lifetime Prevalence of Violence From
Dating Partners Among Adolescent Girls Attending Massachusetts Public High
Schools, by Age and Race/Ethnicity*

Significant differences across age groups were revealed through χ2 analyses for "sexual violence only" (P<.001)
in 1997 and for "physical and sexual violence" in both 1997 (P = .001) and 1999 (P = .004). Younger female
students appeared to be at reduced risk in cases where age-related differences
were detected. Results of χ2 analyses also indicated significant
differences across racial/ethnic groups for "sexual violence only" in both
1997 (P = .045) and 1999 (P
= .008) and for "physical and sexual violence" in 1997 (P = .002). Because of the change in assessment of race/ethnicity in
1999, comparisons are not possible across survey years. Using the 1997 classification,
black female students appear to be more likely than individuals from other
groups to report sexual violence in the absence of physical violence from
dating partners (although caution is warranted based on the wide CI for this
estimate). In contrast, data related to the 1999 classification indicate that
black high school students may be at reduced risk relative to their peers
from other racial/ethnic groups for experiencing sexual violence from dating
partners.

Bivariate Relationships Between Dating Violence and Health Risk

Bivariate logistic regression analyses of data from both survey years
indicate that experience of physical dating violence (without reported sexual
violence) was associated with substance use (heavy smoking, binge drinking,
driving after drinking, cocaine use), unhealthy weight control (diet pill
use, laxative use), sexual risk behavior (first intercourse before the age
of 15 years, not using a condom at last intercourse, ≥3 sex partners in
the past 3 months), pregnancy, and suicidality (considered suicide, attempted
suicide) among female adolescents (Table
2). Experiencing physical dating violence was also found to predict
substance use before last intercourse in analyses of 1997 YRBS data.

In bivariate logistic regression analyses involving both 1997 and 1999
YRBS data, experience of sexual dating violence (without reported physical
violence) was associated with substance use (heavy smoking, driving after
drinking, cocaine use), diet pill use, sexual risk behavior (intercourse before
the age of 15 years, substance use before last intercourse), and suicidality
(considering suicide, attempting suicide). Analyses of the 1999 data set indicated
that experiencing sexual dating violence was also associated with binge drinking,
laxative use and/or vomiting to lose weight, not using a condom at last intercourse,
having 3 or more sex partners in the past 3 months, and having been pregnant.

Experience of both physical and sexual dating violence among adolescent
girls was associated with all assessed forms of substance use, unhealthy weight
control, and suicidality behaviors and pregnancy in analyses of both survey
years. In the area of sexual risk behavior, first intercourse before the age
of 15 years and having 3 or more sex partners in the past 3 months were additionally
associated with experiences of both physical and sexual dating violence. Substance
use before last intercourse was associated with experiencing both physical
and sexual dating violence in bivariate analyses of 1997 YRBS data.

Multivariable Analyses of Relationships Between Dating Violence and
Health Risk

Multiple logistic regression equations constructed to include potential
confounders (demographics and other health risks related to both dating violence
and predicted outcomes) of bivariate relationships of dating violence to adolescent
health risk behaviors yielded similar results. In analyses of both survey
data sets, experience of physical dating violence continued to be associated
with heavy smoking, cocaine use, use of diet pills, laxatives, and/or vomiting
to lose weight, intercourse before the age of 15 years, pregnancy, and both
considering and attempting suicide (Table
3). Not using a condom at last intercourse was also associated with
experiencing physical dating violence in analyses of 1997 YRBS data; binge
drinking and having 3 or more sex partners in the past 3 months were associated
with experiencing physical dating violence in analyses involving 1999 YRBS
data.

Experiencing sexual abuse by dating partners remained significantly
associated with cocaine use, intercourse before the age of 15 years, and considering
and attempting suicide in analyses of both 1997 and 1999 YRBS data. Heavy
smoking and driving after drinking were associated with sexual dating violence
in analyses of 1997 YRBS data; binge drinking, laxative use and/or vomiting
to lose weight, having 3 or more sex partners in the past 3 months, and pregnancy
were associated with sexual violence by dating partners in analyses of the
1999 YRBS data.

In multivariable analyses of data from both survey years, experience
of both physical and sexual dating violence was a significant independent
predictor of substance use (heavy smoking, binge drinking, cocaine use), unhealthy
weight control (diet pill use, laxative use, or vomiting), sexual risk behavior
(intercourse before the age of 15 years, ≥3 sex partners in the past 3
months), pregnancy, and both considering and attempting suicide. Driving after
drinking was additionally predicted by physical and sexual dating violence
in analyses of 1997 YRBS data.

COMMENT

Adolescent girls reported experiencing high rates of physical and sexual
violence from dating partners. Approximately 1 in 5 adolescent girls (18%-20%)
reported being physically and/or sexually hurt by a dating partner in 2 independent
representative surveys of Massachusetts public high school students. A recent
nationally representative survey of adult women found a 25% lifetime prevalence
of IPV.1 The comparability of lifetime prevalence
rates for adolescents and adults suggests that the incidence rate of partner
violence against adolescent girls may be higher than for adult populations.
This is consistent with findings that younger age places females at relatively
higher risk for IPV.1,2

In this study, there were few differences between adolescent girls who
reported only sexual dating violence and those who reported only physical
dating violence in terms of associated health risk behaviors; only use of
diet pills to lose weight was predicted by physical and not sexual violence
across both surveys. Thus, distinctions among forms of dating violence experienced
may not be helpful in assessing other risks associated with such experiences.
In addition, use of "sexual violence only" as an exclusive variable may be
less informative than "physical and sexual violence" during investigations
of sexual dating violence. As seen in Table
1, most cases of sexual dating violence in both surveys were reported
within the "physical and sexual violence" category. This study's finding that
sexual violence from dating partners is less likely to occur in the absence
of some experience of physical partner violence is supported by results of
the recent National Violence Against Women Survey.1
Data from that survey indicate that less than one third of women reporting
rape by an intimate partner report no physical IPV.1

Younger adolescent girls were found to be at lower risk for experiences
of dating violence. This may be due to reduced opportunity for such experiences
among younger girls based on their relatively lower prevalence of dating or
sexual activity and the cumulative nature of lifetime prevalence assessment.
Findings were inconclusive regarding racial/ethnic differences in reports
of dating violence. This assessment may have been hindered by the relatively
small numbers of nonwhite participants and the inconsistency in assessment
of race/ethnicity across survey years.

Adolescent girls who reported abuse from dating partners were found
to be at significantly elevated risk for a broad range of serious health concerns
in analyses of data from both the 1997 and 1999 YRBSs, even after controlling
for the effects of confounding risk behaviors and demographics. These risks
included being more likely to (1) use alcohol, tobacco, and cocaine, (2) engage
in unhealthy weight control, (3) engage in sexual health risk behavior, including
first intercourse before the age of 15 years and multiple partnering, (4)
have been pregnant, and (5) seriously consider or attempt suicide. Of further
importance is that many of the risks associated with experiences of either
physical or sexual dating violence (eg, unhealthy weight control, pregnancy,
suicidality) were heightened for adolescent girls who reported both forms
of abuse.

Previous studies22,23 have
found that smoking, binge drinking, and cocaine use are higher among adolescent
and adult females who experience sexual and/or physical abuse not specific
to dating partners. Our study confirms these findings for a representative
sample of high school girls who experienced abuse from dating partners. However,
we cannot know from this type of cross-sectional data whether experiencing
dating violence places adolescent girls at greater risk for substance use,
whether substance use places adolescent girls at greater vulnerability to
violence from dating partners, or whether other factors place them at higher
risk for both of these concerns.

Similar to studies of severe physical dating violence15
and sexual abuse not specific to dating partners,22,24- 27
adolescent girls who reported experiencing both physical and sexual IPV were
more likely to report having experienced early first intercourse and having
multiple recent sexual partners. What cannot be concluded from these findings
is to what extent earlier sexual experiences were abusive or coercive in nature,
thus accounting for the high association with sexual and physical dating violence.
Similarly, it is not possible to conclude whether multiple partnering practices
put these adolescents at greater risk due to increased exposure to potentially
abusive dating partners, whether dating violence affects adolescent girls
such that they are more likely to seek multiple sexual partners, or whether
external factors not examined confer increased risk for both concerns. These
data do imply, regardless of directionality or mechanism, that adolescent
girls experiencing dating violence are at significantly elevated risk for
having greater numbers of sex partners, making them likely more vulnerable
to contracting human immunodeficiency virus and other sexually transmitted
diseases than adolescent girls who are not abused by dating partners.

High school girls reporting experiences of violence from dating partners
were found to be approximately 4 to 6 times more likely than their nonabused
peers to have ever been pregnant in this study. This finding advances previous
work in the area of teen pregnancy and abuse that has focused on sexual assault
not specific to partners26- 28
and partner abuse among nonrepresentative clinical samples.29
A major limitation of the present assessment, however, is the inability to
determine whether an abusive dating partner was involved in the pregnancy.
Furthermore, the mechanism and chronology involved in the relation between
dating violence and pregnancy cannot be described by these data. It remains
unclear, for instance, whether dating violence is associated with inability
to use contraception and, if so, whether abusive partners actively prevent
contraception or whether abused teens fear attempting to implement such measures.
Although it may also be possible that other factors are responsible for both
the occurrence of dating violence and pregnancy among adolescents, the implicit
coercion involved in both sexual and physical partner abuse is likely to have
implications for pregnancy prevention.

Unhealthy weight control behaviors (using diet pills, laxatives, or
vomiting to lose weight) were also more prevalent among adolescent girls who
reported experiencing violence from dating partners. Earlier work has found
that both adolescent girls30 and adult women31,32 who experienced forced sex are more
likely to exhibit eating disorders. However, physical IPV was not associated
with eating disorders in adults,31 and when
other risk factors were accounted for including physical abuse in the adolescent
study, sexual abuse was no longer related to eating disorders.30
In this study, both sexual and physical violence from dating partners predicted
unhealthy weight control behaviors after controlling for the effects of potential
confounders.

Finally, recent suicide ideation and actual suicide attempts were approximately
6 to 9 times as common among adolescent girls who reported having been sexually
and physically hurt by dating partners. These disturbing findings advance
previous work identifying associations between both severe dating violence
and sexual assault not specific to dating partners and suicidality.16,24- 27
The pain and humiliation of those who experience IPV may play a major role
in predisposing teens to suicidal ideation and behavior. Furthermore, based
on recent data from abused adults,33 adolescents
who experience dating violence may be less likely than other teens to receive
treatment for mental health concerns.

Limitations

There are several important limitations to this study. The reliance
on a single item with limited known validity to assess dating violence may
be considered less reliable than a detailed, multiple-item instrument with
known psychometrics. Lack of information on the specific forms or severity
of reported violence, duration and recency of this abuse, and current relationship
to the perpetrator also limits the nature of hypotheses tested and our interpretation
of results. In addition, risk behaviors assessed in this study may be more
prevalent among adolescents with poorer school attendance, who were, therefore,
less likely to participate in the survey. Hence, the risk behaviors examined
may be underestimated and the relationships assessed biased because of the
potentially nonrepresentative nature of this sample. We also do not know whether
the findings from this sample of public high school attendees generalize to
other groups of adolescents, such as private high school students or individuals
who have dropped out of high school. In addition, we were unable to directly
assess the sex of dating partners involved in reported violence. However,
most sexual partners reported by participants were male (98.0% reported heterosexual
sexual contact; 95.6% reported no same-sex sexual contact). Thus, the portion
of dating violence perpetrated by female partners is likely to be small. Finally,
limited categories for race/ethnicity within these surveys, differences in
assessment of race/ethnicity across survey years, and the smaller numbers
of participating racial/ethnic minority students limit understanding of how
the issues investigated may differ across different racial/ethnic groups.

Conclusions

Although the results of this study clearly demonstrate a link between
health risk behavior and the experience of dating violence among adolescent
girls, further research is necessary to identify mechanisms by which violence
from dating partners may relate to other health risk behaviors and determine
the chronology of these factors. Both longitudinal studies and large-scale
qualitative examinations are needed to identify the direction of associations
between dating violence and health risks and to provide insight into the etiology
of dating violence and associated adolescent risk behavior.

Furthermore, although this study focuses on those who have experienced
abuse, perhaps the most pressing need for research involves the development
of this behavior among perpetrators of abuse against dating partners. Parents
and peers appear to play a role in supporting adolescent males' violence toward
dating partners,34,35 but we know
little of the other social contexts and experiences that make perpetration
of IPV more likely. Moreover, we know even less about what developmental factors
make this behavior less likely. Identification and support of such resiliency
factors may interrupt the development of abusive male behavior and thus prevent
dating violence and adult IPV and its many potential deleterious effects on
female health.

Despite the need for additional research, findings of this study have
significant implications for prevention programming with adolescents in a
number of important areas. First, violence against adolescent girls from dating
partners is extremely prevalent. As a result, prevention efforts in this area
should be expanded, and support should be provided for development and implementation
of prevention programs and services specific to teen dating violence. Second,
as in cases of IPV against adults, health care professionals may play a crucial
role in identifying those who have experienced dating violence and offering
assistance. Medical and mental health professionals should routinely screen
adolescents for dating violence and be aware of appropriate referrals.14 Finally, our findings strongly indicate that girls
who experience dating violence are at greater risk for other serious adolescent
health concerns. Therefore, practitioners working to combat substance use,
risky sexual behavior, pregnancy, eating disorders, and suicide among teens
should address dating violence as a potential factor in all of these behaviors.

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